From the Robert Wood Johnson Foundation's Aligning Forces for Quality Program:
More than 80 participants gathered in Dallas September 19-20 to discuss bridging the gap between health care and population health. Representatives from each Alliance and outside guests, community partners involved in population health projects, joined staff from the National Program Office and the Robert Wood Johnson Foundation to share experiences—both successes and frustrations—as they move toward addressing population health issues as they continue their work with Aligning Forces for Quality—and beyond.
The meeting kicked off with a dinner featuring keynote speaker T.R. Reid, noted journalist and author. “Building models for national reform is an ingenious idea, and it’s working,” he told the group. “Where AF4Q is working, it’s really making a difference.”
Reid touched on different models for health care—the Beveridge, Bismarck, Douglas, and “Out-of-Pocket” models (such as that used in the United States)—with some examples of where these models are being used and what the big picture for health care quality is in those areas.
The common thread? In every country, the poor have a higher rate of illness and a lower rate of recovery from illness. They die younger, even in places like Great Britain that provide health care to everyone for free. This, suggested Reid, is where attention to population health steps in.
The following day four panels discussed on how to connect health care and population health. In “Pulling the Correct Levers to successfully Connect Health Care and Population Health,” panelists hit the ground running by defining the two. “Public health has the mission, but health care has the money,” said Patrick Remington, associate dean for public health at the University of Wisconsin School of Medicine and Public Health. “Align the money with the mission.” The panelists also discussed how the differences between the two might allow for synergy.
Jim Hester, former director of the Population Health Models Group, Center for Medicare & Medicaid Innovation, said that developing a community health system that gets at the root of illness is critical. “Start with the determinants of health model and work at all levels,” he said. He also stressed the importance of finding a sustainable payment model. “Get away from dependence on grants,” he advised.
“The financial payment model is a key lever in this work,” he said. “Payment models have been a barrier to population health. We need a portfolio of interventions to improve pop health, not just one mechanism. How can we tap into different sources of funding and use that support for new interventions?”
Peter Briss, medical director at the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, stressed the importance of convening stakeholders when attempting to improve population health. Doing so can help identify and spread what really works and enable partnering organizations to address the most important drivers, such as payment, data infrastructure, and measurement such as the County Health Rankings. It’s important to identify those drivers and any areas of need and then match dollars to those needs. “It’s easier to bring stakeholders together if you have standing,” he said, “but you can still accomplish something through coalition building, even though it’s hard, slow, hand-to-hand combat.”
ACA and Population Health
Many aspects of the Affordable Care Act (ACA) are pushing and will continue to push health care stakeholders to work more closely with population health-focused organizations in their communities to keep people health. This momentum will open up opportunities, but it obviously creates challenges as well.
“Expanded community health needs assessment and community benefit requirements for non-profit hospitals are an opening for not just public health stakeholders to partner with hospitals, but also community-based groups not traditionally associated with health care,” said Jessica Curtis, director of the Hospital Accountability Project, Community Catalyst. But she warned of an information gap in the communities—a gap Alliances are poised to fill by communicating clearly how these new requirements can work in their communities to create new partnerships to promote health.
Nalini Pande, principal policy director at American Institutes for Research, agreed communication is key, but added that a boots-on-the-ground approach, like the one taken by the P2 Collaborative of Western New York, is out in the community measuring and focusing on social determinants, is a key in bridging the gap. Nevertheless, she said, “Alliances need to think through the reality of your community and what is feasible. Success might be incremental.”
Despite the potential for better partnerships and more effective communication that would come about with ACA implementation, concerns remain. Offering a government agency perspective, Princess Jackson, director of the Dallas region for the Health Resources & Services Administration (HRSA), told the gathering that HRSA is looking at helping organizations provide resources to anyone regardless of their ability to pay. They’re concerned about the number of patients who will still be uninsured after ACA implementation. Jackson said AF4Q and HRSA should work together on these issues and there are many HRSA grantees that, while working to sign up people for insurance, are doing great work in their communities to connect patients with community resources.
This session about patients who comprise a small percentage of the population but who account for a huge percentage of health care costs offered some excellent examples of groups that have made a big difference in their communities by addressing this issue connecting high-utilizers of health care with community resources to keep them healthy.
In Doug Eby’s Anchorage community, Nuka, an Alaska Native-owned and -run health safety net system organization built their organization with a customer-owned and customer-designed approach that helped them see, in Eby’s words, “we need to quit doing things topeople. We need to connect with their hopes and aspirations.” Nuka’s outcomes have been impressive, accomplished through an integrated care team, an approach mirrored by the communities of the other panelists. Both the Community Medicaid Collaborative (CMC) in Niagara Falls and the Austen BioInnovation Institute in Akron use similar community-based approaches. CMC uses care coordinators and community health workers in primary care settings, empowering neighborhoods and working for culture change at all levels. The Austen BioInnovation Institute focused on community health from a perspective of building the community by returning some cost savings to the accountable care community—so named because it connects with nontraditional stakeholders like parks and transportation—and investing some in new initiatives. Janine Janosky, vice president of medical services at Austen, stressed that collaboration is a process with collective impact as the outcome—system redesign hinges on knowing when an implemented program is not meeting objectives.
All panelists agreed that using community health workers usually works and that the next step is to expand their use.
“Deep personal relationships formed between patients and community health workers is how you make interventions work in the community,” Eby said.
What Could Work?
The final panel explored examples of communities that are successfully bridging the gap between population health and health care. At Hennepin Health, they’re redesigning care through an ACO focused on Medicaid patients. In one year, the ACO in Hennepin County reduced health care costs for participating patients by 30 percent, according to Nancy Garret, director of the Analytics Center of Excellence at Hennepin Health. They’ve created a data warehouse so they can get the whole picture of the patient from multiple sources inside and outside the health care system. They are also bringing dental care into medical settings to make it easier to treat the whole person.
Cambridge Health Alliance has achieved success by using evidence-based practices, identifying roles and responsibilities, reviewing data, determining shared priorities with community partners, and monitoring progress. “Incremental strategies are a great way of getting people started and have a better chance of sustainability,” said Karen Hacker, formerly of the Camden Health Alliance and currently head of the Allegheny Health Department. Through this approach, Camden improved childhood asthma rates so much they closed down their unit.
“You need people in your organization who are bridge builders,” said Hacker.
For Healthy Livable Communities Consortium of Cattaraugus County in New York, the bridge builder was the P² Collaborative, AF4Q’s Alliance in Western New York. The Alliance plays the part of the community integrator. “In all of our worlds, we lean one way or another, and we know we need objectivity—P² Collaborative provided that for us,” said Cattaraugus’s Public Health Educator Debra Nichols.